Five-Year Experience with Fifth-to-Seventh Nerve Transfer for Smile:

Masseteric-facial anastomosis and hypoglossal-facial anastomosis after lateral skull base and middle ear surgery

INTRODUCTION

Lateral skull base (LSB) and middle ear pathologies often involve the facial nerve (FN), and their treatment may require FN sacrifice. Cases with unidentifiable proximal stump or intact FN with complete FN palsy, necessitate FN anastomosis with another motor nerve in order to restore innervation to the mimicking musculature. The results of hypoglossal-to-facial nerve anastomosis (HFA) and masseteric-facial nerve anastomosis in patients with facial paralysis after middle ear and LSB surgeries, are presented and compared.

METHODS

Adult patients with total definitive facial paralysis after middle ear or LSB surgery undergoing facial nerve reanimation through hypoglossal or masseteric transfer anastomosis were enrolled. The facial nerve function was graded according to the House Brackmann grading system (HB). The facial function results at 3 months, 6 months, 12 months, 18 months and at the last follow up (more than 18 months) are compared.

RESULTS

153 cases of LSB and middle ear surgery presented postoperative facial palsy and underwent facial nerve reanimation surgery with HF in 85 patients (55.5%) and MF in 68 patients (44.5%). The duration of the FN palsy before reconstructive surgery was inversely associated to better FN results, in particular with having a grade III HB (p = 0.003). Both techniques had significantly lower HB scores when an interval between palsy onset and reanimation surgery was 6 months or less (MF p = 0.0401; HF p = 0.0022). Patients who underwent a MF presented significant improvement of the FN function at 3 months from surgery (p = 0.0078). At the last follow-up, 63.6% recovered to a grade III HB and 22.7% to a grade IV. On the other hand, the first significant results obtained in the HF group were at 6 months from surgery (p < 0.0001). 67.8% of patients had a grade III HB after a HF at the last follow-up, 28.8% a grade IV. FN grading at 6 months from surgery was significantly lower in the MF group compared to the HF (p = 0.0351). The two techniques had statistically similar results at later follow-up evaluations.

DISCUSSION/CONCLUTION

MF was associated to initial superior results, presenting significant facial recovery at 3 months, and significantly better functional outcomes at 6 months from surgery compared to HF. Although later results were not significantly different in this study, earlier results have an important role in order to limit the duration of risk of corneal exposure.

Functional Outcome of Dual Reinnervation with Cross-Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis

BACKGROUND

The combination of cross-facial nerve graft (CFNG) and masseteric nerve transfer (MNT) for reinnervation of facial paralysis may provide advantages of both neural sources. However, quantitative functional outcome reports with a larger number of patients are lacking in the literature. Here, the authors describe their 8-year experience with this surgical technique.

METHODS

Twenty patients who presented with complete facial paralysis (duration, <12 months) received dual reinnervation with CFNG and MNT. The functional outcome of the procedure was evaluated with the physician-graded outcome metric eFACE scale. The objective artificial intelligence-driven software Emotrics and FaceReader were used for oral commissure measurements and emotional expression assessment, respectively.

RESULTS

The mean follow-up was 31.75 ± 23.32 months. In the eFACE score, the nasolabial fold depth and oral commissure at rest improved significantly ( P < 0.05) toward a more balanced state after surgery. Postoperatively, there was a significant decrease in oral commissure asymmetry while smiling (from 19.22 ± 6.1 mm to 12.19 ± 7.52 mm). For emotional expression, the median intensity score of happiness, as measured by the FaceReader software, increased significantly while smiling (0.28; interquartile range, 0.13 to 0.64). In five patients (25%), a secondary static midface suspension with fascia lata strip had to be performed because of unsatisfactory resting symmetry. Older patients and patients with greater preoperative resting asymmetry were more likely to receive static midface suspension.

CONCLUSION

The authors' results suggest that the combination of MNT and CFNG for reinnervation of facial paralysis provides good voluntary motion and may lessen the use of static midface suspension in the majority of patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Facial synkinesis: A distressing sequela of facial palsy

INTRODUCTION

Synkinesis refers to abnormal involuntary facial movements that accompany volitional facial movements. Despite a 55% incidence of synkinesis reported in patients with enduring facial paralysis, there is still a lack of complete understanding of this debilitating condition, leading to functional limitations and decreased quality of life.1 This article reviews the diagnostic assessment, etiology, pathophysiology, rehabilitation, and nonsurgical and surgical treatments for facial synkinesis.

METHODS

A PubMed and Cochrane search was done with no date restrictions for English-language literature on facial synkinesis. The search terms used were "facial," "synkinesis," "palsy," and various combinations of the terms.

RESULTS

The resultant inability to control the full extent of one's facial movements has functional and psychosocial consequences and may result in social withdrawal with a significant decrease in quality of life. An understanding of facial mimetic musculature is imperative in guiding appropriate intervention. While chemodenervation with botulinum toxin and neurorehabilitation have continued to be the primary treatment strategy for facial synkinesis, novel techniques such as selective myectomy, selective neurolysis, free-functioning muscle transfer, and nerve grafting techniques are becoming increasingly utilized in treatment regimens. Facial rehabilitation, including neuromuscular retraining, soft tissue massage, and relaxation therapy in addition to chemodenervation with botulinum toxin, remains the cornerstone of treatment. In cases of severe, intractable synkinesis and non-flaccid facial paralysis, surgical interventions, including selective neurectomy, selective myectomy, nerve grafting, or free muscle transfer, may play a more significant role in alleviating symptoms.

DISCUSSION

A multidisciplinary approach involving therapists, clinicians, and surgeons is necessary to develop a comprehensive treatment regimen that will result in optimal outcomes. Ultimately, therapy should be tailored to the severity and pattern of synkinesis, and each patient approached on a case-by-case basis. A multidisciplinary approach involving therapists, clinicians, and surgeons is necessary to develop a comprehensive treatment regimen that will result in optimal outcomes.

Quality of life after surgical treatments for facial palsy: A systematic review and meta-analysis

BACKGROUND

Facial palsy profoundly affects patients' quality of life (QoL). We evaluated the effect of various surgical procedures on QoL using patient-reported outcome measures (PROMs) to provide evidence-based recommendations for improved care.

METHODS

Embase, Medline, Web of Science, Cochrane, and CINAHL were searched for studies on QoL in patients with facial palsy who had undergone reconstructive surgery with preoperative and postoperative data from validated PROMs. After conducting the quality assessment, data were subtracted from the articles. Meta-analyses of subgroups were performed when study outcomes where compatible.

RESULTS

Incorporating 24 studies (522 patients), our systematic review revealed consistent and significant QoL improvements following diverse reconstructive surgical procedures.

CONCLUSIONS

Our systematic review and meta-analysis showed the positive effects of different reconstructive surgical procedures on QoL of patients with facial palsy. These results support clinicians to better inform patients about their potential outcomes, optimizing informed and shared decision-making and ultimately improving overall QoL in patients with facial palsy.

Masseteric Nerve Transfer for Facial Paralysis Secondary to Parotid Malignancy: A Retrospective Case Series

Background: The objective outcomes of masseteric nerve transfer in the setting of parotid malignancy are unclear. Objective: To measure objective facial reanimation outcomes of masseteric nerve transfer in patients with parotid malignancy who underwent parotidectomy with facial nerve resection. Materials and Methods: Retrospective review of patients who underwent masseteric nerve transfer for facial paralysis secondary to parotid malignancy was carried out at a tertiary referral hospital from August 2017 to November 2021. Objective facial reanimation outcomes were analyzed using Emotrics. Minimal follow-up of 6 months was required for inclusion. Results: Eight patients (five males) with a median age of 75.5 years (range 53-91) met inclusion criteria. Fifty percent had metastatic squamous cell carcinoma, and 50% had primary parotid malignancy. Five patients underwent concomitant cancer resection with facial nerve reconstruction. Seven patients received postoperative adjuvant radiotherapy. After reinnervation, patients had improved oral commissure excursion (from 1.51 mm ±1.27 to 3.77 mm ±1.81; p < 0.01) and facial symmetry during smile. Conclusion: In this study, masseteric nerve transfer enhanced oral commissure excursion and facial symmetry during smile in patients with parotid malignancy and facial nerve resection.

The masseteric nerve for facial reanimation: Macroscopic and histomorphometric characteristics in 106 human cadavers and comparison of axonal ratio with recipient nerves

Peripheral facial palsy causes severe impairments. Sufficient axonal load is critical for adequate functional outcomes in reanimation procedures. The aim of our study was to attain a better understanding of the anatomy of the masseteric nerve as a donor, in order to optimize neurotization procedures. Biopsies were obtained from 106 hemifaces of fresh frozen human cadavers. Histological cross-sections were fixed, stained with PPD, and digitized. Histomorphometry and a validated software-based axon quantification were conducted. Of the 154 evaluated branches, 74 specimens were of the main trunk (MT), 40 of the anterior branch (AB), and 38 of the descending branch (DB), while two halves of one cadaver featured an additional branch. The MT showed a diameter of 1.4 ± 0.41 mm (n = 74) with 2213 ± 957 axons (n = 55). The AB diameter was 0.9 ± 0.33 mm (n = 40) with 725 ± 714 axons (n = 30). The DB diameter was 1.15 ± 0.34 mm (n = 380) with 1562 ± 926 axons (n = 30). The DB demonstrated a high axonal capacity - valuable for nerve transfers or muscle transplants. Our findings should facilitate a balanced selection of axonal load, and are potentially helpful in achieving more predictable results while preserving masseter muscle function.

The surgical anatomy of the deep temporal nerve: A cadaveric study

BACKGROUND

The aims of this study were to investigate the surgical anatomy of the deep temporal nerve (DTN) and find (fixed/static) anatomical landmarks that could be used during surgery to localise the DTN branches.

METHODS

Ten hemifaces of Dutch cadavers were dissected at the Department of Anatomy of the Radboudumc. Landmarks and measurements of interest were number of branches of the DTN, distance from the tragus to the DTN, and distance from the cranial and caudal parts of the posterior root of the zygomatic bone until the DTN.

RESULTS

In this cadaveric study, 10 hemifaces were dissected (male, n = 6 [60%]; female, n = 4 [40%]) with an equal left/right side division. The number of deep temporal branches varied from 2 (30%) to 3 (70%) per side. The mean distance to the tragus varied from 40 to 53 mm, with a mean distance of 44.3 ± 4.4 mm. The mean distance from the cranial part of the posterior root of the zygomatic bone to the DTN varied from 29 to 35 mm, with a mean distance of 31.3 ± 2.1 mm. The distance from the caudal part of the posterior root of the zygomatic bone to the DTN varied from 8 to 17 mm, with a mean distance of 13.4 ± 3.4 mm.

CONCLUSION

This study investigated the surgical anatomy and landmarks used for identification of the DTN and its branches. It suggested using firm landmarks for nerve identification, such as the posterior root of the cranial and/or the caudal zygomatic bone.

The Selective Trigeminal Nerve Motor Branching Transfer: an Preliminary Clinical Application for Facial Reanimation

OBJECTIVE

To investigate the effectiveness and feasibility of selective trigeminal nerve motor branching in the repair of facial palsy.

MATERIALS AND METHODS

The clinical data of patients with advanced facial palsy from 2016 to 2021 were retrospectively analyzed, including pictures and videos before and 18 months after surgery. The House-Brackmann grading system was used to evaluate facial nerve function before and after repair, and the symmetry scale of oral commissure at rest and Terzis' smile functional evaluation scale were used to qualitatively assess the symmetry of the mouth angle and smile function. The distance of oral commissure movement was assessed to evaluate the dynamic repair effect, and the FaCE facial muscle function scale was used to assess patients' subjective perception before and after surgery.

RESULTS

A total of four patients were included in the study, all of whom showed signs of recovery of facial nerve function within six months. In all four cases, significant improvements were observed in House-Brackmann ratings, the smile function score and the symmetry scale of oral commissure at rest. Compared to the pre-operative period, the four patients demonstrated various degrees of eye-closing function recovery, and a significant improvement in oral commissure movement was observed ( P <0.001). FaCE scores also improved significantly after surgery ( P =0.019).

CONCLUSION

Concurrent selective facial nerve repair with trigeminal branch-facial nerve anastomosis resulted in eye-closing function recovery while improving static and dynamic symmetry, yielding acceptable postoperative results.

Facial Reanimation After Peripheral Facial Nerve Paralysis: A Single-institution Surgical Experience

Facial nerve trauma occasionally develops during oral and maxillofacial surgery. This study was aimed at enhancing the available knowledge on facial nerve reanimation correlated to surgery and proposing our surgical algorithm. We retrospectively analyzed medical records of patients who underwent facial reanimation surgery at our hospital. The inclusion criterion was surgery for facial reanimation from January 2004 to June 2021. We included 383 eligible patients who underwent facial reanimation surgery. Trauma or maxillofacial neoplasms were noted in 208 of 383 and 164 of 383 cases, respectively. In 238 of 383 cases, nerve branches were likely more vulnerable. Facial nerve anastomosis was performed in 256 patients. Sixty-eight patients received nerve grafts. In 22 patients, distal facial nerve transfer to the masseteric nerve, sublingual nerve, or contralateral facial nerve was performed. Twenty-five patients received static surgery; in most cases, the temporalis fascia flap (20/25) was used. The nerve function outcomes were HB grade I (n=17), Grade Ⅱ (n=108), Grade Ⅲ (n=118), Grade Ⅳ (n=94), and Grade V (n=46). The mean follow-up time was 4.88 ± 3.93 years. Facial paralysis caused by trauma ( P =0.000), branch injury ( P =0.000), and the primary reconstruction of facial nerve ( P =0.000) were predictive of favorable treatment outcomes. Although facial nerve injury caused by trauma was more likely, cases of interference in facial expression could be limited, and so did the injury to branches. Nerve anastomosis was prioritized if a tension-free suture was possible. Maintaining the integrity of the nerve and shortening the duration of mimetic muscular denervation were crucial.

Advances in Facial Reanimation

Facial nerve paralysis is a debilitating clinical entity that presents as a complete or incomplete loss of facial nerve function. The etiology of facial nerve palsy and sequelae varies tremendously. The most common cause of facial paralysis is Bell's palsy, followed by malignant or benign tumors, iatrogenic insults, trauma, virus-associated paralysis, and congenital etiologies.

Microvascular Gracilis Free Flap: Single and Double Innervation

Facial paralysis (FP) is a devastating condition that can lead to significant aesthetic, social, and emotional morbidities for patients. For some patients with FP, free gracilis muscle transfer (FGMT) is the best option for smile restoration. Masseteric-driven FGMT produces a reliable voluntary smile. Cross-face nerve graft-driven FGMT can produce a spontaneous smile, but this technique has higher failure rates. Early studies suggest dual-innervation FGMT can produce a spontaneous smile while maintaining the reliability of masseteric-driven procedures. Great care should be taken during FGMT surgery to minimize facial bulk and place medial inset sutures that create a natural-appearing smile.

The Role of the Cross Face Nerve Graft in Facial Reanimation and Endoscopic Harvest of the Sural Nerve

Cross-face nerve grafting (CFNG) allows for spontaneous, involuntary facial movement for patients with irreversible hemifacial paralysis. This technique uses an intact contralateral facial nucleus and nerve as an input and axon source, allowing donor neural input to be routed through a nerve graft across the face. The sural nerve is well equipped for use as a nerve graft due to its length and minimal donor site morbidity. Endoscopic nerve harvest techniques allow for efficient, minimally invasive dissection that improves the integrity of the harvested nerve.

Early Simultaneous Cross Facial Nerve Graft and Masseteric Nerve Transfer for Facial Paralysis after Tumor Resection

We describe a new approach for facial reanimation after skull base tumor resection with known facial nerve sacrifice, involving simultaneous masseter nerve transfer with selective cross facial nerve grafting (CFNG) within days after tumor surgery. This preliminary study compared outcomes of this approach versus a staged procedure involving a masseter nerve "babysitter" performed in a delayed timeline.

Methods

Patients undergoing masseter nerve transfer and CFNG for facial paralysis after skull base tumor resection were consented to participate in video interviews. Facial Clinimetric Evaluation (FaCE) Scale (0-100) patient-reported outcome, eFACE, and Facial Grading Scale scores were compared.

Results

Nine patients had unilateral facial paralysis from resection of a schwannoma (56%), acoustic neuroma (33%), or vascular malformation (11%). Five underwent early simultaneous CFNG and masseter nerve transfer (mean 3.6 days after resection), whereas four underwent two-stage reanimation including a babysitter procedure (mean 218 days after resection). Postoperative FaCE scale and Facial Grading Scale scores were similar in both groups (P > 0.05). Postoperative mean eFACE scores were similar for both groups for smile (early: 71.5 versus delayed: 75.5; P = 0.08), static (76.3 versus 82.1; P = 0.32), and dynamic scores (59.7 versus 64.9; P = 0.19); however, synkinesis scores were inferior in the early group (76.4 versus 91.1; P = 0.04).

Conclusions

Early simultaneous masseter nerve transfer and CFNG provides reanimated movement sooner and in fewer stages than a staged approach in a delayed timeline. The early technique appears to result in similar clinician- and patient-reported outcomes compared with delayed procedures; however, in this preliminary study, the early approach was associated with greater synkinesis, meriting further investigation.

Multiple Model Evaluation of the Masseteric-to-Facial Nerve Transfer for Reanimation of the Paralyzed Face and Quick Prognostic Prediction

Facial paralysis is negatively associated with functional, aesthetic, and psychosocial consequences. The masseteric-to-facial nerve transfer (MFNT) has many advantages in facial reanimation. The aim is to evaluate the effectiveness of our MFNT technique and define the potential factors predictive of outcome. The authors conducted a retrospective review of 20 consecutive patients who underwent MFNT using the temporofacial trunk of facial nerve. Videotapes and images were documented and evaluated according to Facial Nerve Grading Scale 2.0 (FNGS2.0) and Sunnybrook Facial Grading System (FGS). The quality-of-life was obtained using the Facial Clinimetric Evaluation (FaCE) Scale. Moreover, Facial Asymmetry Index (FAI), quantitative measurement of the width of palpebral fissure, deviation of the philtrum, and angles or excursions of the oral commissure were applied to explore the effect of the transfer metrically. Multivariable logistic regression models and Cox regression were prepared to predict the effect of MFNT by preoperative clinical features. The patients showed favorable outcomes graded by FNGS2.0, and experienced significantly improved scores in static and dynamic symmetry with slightly elevated scores in synkinesis evaluated by the Sunnybrook FGS. The score of FaCE Scale increased in all domains after reanimation. The quantitative indices indicated the symmetry restoration of the middle and lower face after MFNT. Regression analysis revealed that younger patients with severe facial paralysis are preferable to receive MFNT early for faster and better recovery, especially for traumatic causes. The findings demonstrate that MFNT is an effective technique for facial reanimation, and case screening based on clinical characteristics could be useful for surgical recommendation.

Microanatomy of the Frontal Branch of the Facial Nerve: The Role of Nerve Caliber and Axonal Capacity

BACKGROUND

A commonly seen issue in facial palsy patients is brow ptosis caused by paralysis of the frontalis muscle powered by the frontal branch of the facial nerve. Predominantly, static methods are used for correction. Functional restoration concepts include the transfer of the deep temporal branch of the trigeminal nerve and cross-facial nerve grafts. Both techniques can neurotize the original mimic muscles in early cases or power muscle transplants in late cases. Because axonal capacity is particularly important in cross-facial nerve graft procedures, the authors investigated the microanatomical features of the frontal branch to provide the basis for its potential use and to ease intraoperative donor nerve selection.

METHODS

Nerve biopsy specimens from 106 fresh-frozen cadaver facial halves were obtained. Histologic processing and digitalization were followed by nerve morphometric analysis and semiautomated axon quantification.

RESULTS

The frontal branch showed a median of three fascicles (n = 100; range, one to nine fascicles). A mean axonal capacity of 1191 ± 668 axons (range, 186 to 3539 axons; n = 88) and an average cross-sectional diameter of 1.01 ± 0.26 mm (range, 0.43 to 1.74 mm; n = 67) were noted. In the linear regression model, diameter and axonal capacity demonstrated a positive relation (n = 57; r2 = 0.32; p < 0.001). Based on that equation, a nerve measuring 1 mm is expected to carry 1339 axons.

CONCLUSION

The authors' analysis on the microanatomy of the frontal branch could promote clinical use of cross-facial nerve graft procedures in frontalis muscle neurotization and free muscle transplantations.

[Dynamic procedures for facial nerve reconstruction]

In this article the indications and surgical treatment options for patients with facial nerve palsy are discussed. A distinction is made between static and dynamic surgical procedures. Static reconstructions for example are used to restore the eyelid closure function. For smile reconstruction, which is important for the psychosocial life of the patient, dynamic procedures are used. Depending on the duration of the facial nerve paralysis, there are several possibilities to restore the smile. In this work the masseteric branch transposition to the buccal branch, the hypoglossal-facial nerve anastomosis, the Labbé procedure and the gracilis flap as a free muscle transplant are discussed. The surgical procedures are compared and the advantages and disadvantages of the intervention are presented. A spontaneous smile is aimed, this cannot always be achieved. With the masseteric branch transposition to the buccal branch and the Labbé procedure the smile is initially triggered by chewing. A spontaneous smile is possible through cortical adaptation. With the gracilis flap, however, a nerve anastomosis with the contralateral 'healthy' facial nerve is possible, either directly or via a so-called cross facial nerve grafting, whereby a spontaneous smile can be achieved.

Facial paralysis: timing of repair and management of the nonflaccidly paralyzed face

PURPOSE OF REVIEW

To explore recent advances in therapeutic interventions for nonflaccid facial paralysis (NFFP), including new evidence for surgical and nonsurgical treatments. Timing of treatment is also discussed, along with possible future treatments.

RECENT FINDINGS

NFFP remains a difficult disease to treat. Chemodenervation with botulinum toxin remains a first-line treatment to suppress aberrant and antagonistic movements during voluntary use of muscles. More permanent treatments such as selective neurectomy, myectomy, and nerve and muscle transfers have been shown to offer promising results for the nonflaccidly paralyzed face.

SUMMARY

NFFP is commonly seen in patients who have incomplete recovery from facial paralysis, and carries high psychosocial morbidity. A large array of treatments have been described in the literature, both procedural and nonprocedural. Both treatment type and timing are important in optimal patient recovery.

Dual-innervated multivector muscle transfer using two superficial subslips of the serratus anterior muscle for long-standing facial paralysis

Recent reports have described several cases of double muscle transfers to restore natural, symmetrical smiles in patients with long-standing facial paralysis. However, these complex procedures sometimes result in cheek bulkiness owing to the double muscle transfer. We present the case of a 67-year-old woman with long-standing facial paralysis, who underwent two-stage facial reanimation using two superficial subslips of the serratus anterior muscle innervated by the masseteric and contralateral facial nerves via a sural nerve graft. Each muscle subslip was transferred to the upper lip and oral commissures, which were oriented in different directions. Furthermore, a horizontal fascia lata graft was added at the lower lip to prevent deformities such as lower lip elongation and deviation. Voluntary contraction was noted at roughly 4 months, and a spontaneous smile without biting was noted 8 months postoperatively. At 18 months after surgery, the patient demonstrated a spontaneous symmetrical smile with adequate excursion of the lower lip, upper lip, and oral commissure, without cheek bulkiness. Dual-innervated muscle transfer using two multivector superficial subslips of the serratus anterior muscle may be a good option for long-standing facial paralysis, as it can achieve a symmetrical smile that can be performed voluntarily and spontaneously.

Assessment of eye closure and blink with facial palsy: A systematic literature review

Facial palsy can cause the impairment of eye closure and affect blink, ocular health, communication, and esthetics. Dynamic surgical procedures can restore eye closure in patients with decreased facial nerve function. There are no standardized measures of voluntary and spontaneous eye closure that are used to evaluate the outcomes of blink restoration procedures. The purpose of this systematic literature review was to identify the measures used to assess normal and abnormal eye closure and blinking in patients with facial palsy. A literature search of the PubMed database using the keyword "facial nerve/surgery" was conducted. Only English language articles that pertain to the use of facial paralysis assessment systems published in the past 20 years, which involve eyelid closure were included. There were 57 articles that used a facial paralysis classification system with an eyelid closure component: House-Brackmann Facial Nerve Grading Scale (n = 43, 67%); Sunnybrook Facial Grading Scale (n = 9); palpebral fissure heights (n = 4), and the electronic clinician-graded facial function tool (n = 3) and three additional measures were reported once. Although the Terzis and Bruno Scoring System, blink ratio, and electronic, clinician-graded facial function scale(eFACE) Clinician-Graded Scoring System were valid measures of eyelid closure, there was no one comprehensive eye assessment that demonstrated all aspects of eye closure in facial palsy, which include closure amplitude, spontaneity, and quality of life. For blink assessment, eFACE is the most comprehensive tool currently available and recommended to be used with a patient-reported quality of life supplement that captures the specific domains related to facial nerve dysfunction.

Hypoglossal and Masseteric Nerve Transfer for Facial Reanimation: A Systematic Review and Meta-Analysis

Background: Hypoglossal and masseteric nerve transfer are currently the most popular cranial nerve transfer techniques for patients with facial paralysis. The authors performed a systematic review and meta-analysis to compare functional outcomes and adverse effects of these procedures. Methods: A review of online databases was performed to include studies with four or more patients undergoing hypoglossal or masseter nerve transfer without muscle transfer or other cranial nerve transposition. Facial nerve outcomes, time to reinnervation, and adverse events were pooled and studied. Results: A total of 71 studies were included: 15 studies included 220 masseteric-facial transfers, and 60 studies included 1312 hypoglossal-facial transfers. Oral commissure symmetry at rest was better for hypoglossal transfer (2.22 ± 1.6 mm vs. 3.62 ± 2.7 mm, p = 0.047). The composite Sunnybrook Facial Nerve Grading Scale was better for masseteric transfer (47.7 ± 7.4 vs. 33.0 ± 6.4, p < 0.001). Time to first movement (in months) was significantly faster in masseteric transfer (4.6 ± 2.6 vs. 6.3 ± 1.3, p < 0.001). Adverse effects were rare (<5%) for both procedures. Conclusions: Both nerve transfer techniques are effective for facial reanimation, and the surgeon should consider the nuanced differences in selecting the correct procedure for each patient.

Early Outcomes in an Emerging Facial Nerve Center: The Oregon Health and Science University (OHSU) Experience

OBJECTIVES

Nerve transfer (NT) and free gracilis muscle transfer (FGMT) are procedures for reanimation of the paralyzed face. Assessing the surgical outcomes of these procedures is imperative when evaluating the effectiveness of these interventions, especially when establishing a new center focused on the treatment of patients with facial paralysis. We desired to discuss the factors to consider when implementing a facial nerve center and the means by which the specialist can assess and analyze outcomes.

METHODS

Patients with facial palsy secondary to multiple etiologies, including cerebellopontine angle tumors, head and neck carcinoma, and trauma, who underwent NT or FGMT between 2014 and 2019 were included. Primary outcomes were facial symmetry and smile excursion, calculated using FACE-gram and Emotrics software. Subjective quality of life outcomes, including the Facial Clinimetric Evaluation (FaCE) Scale and Synkinesis Assessment Questionnaire (SAQ), were also assessed.

RESULTS

14/22 NT and 6/6 FGMT patients met inclusion criteria having both pre-and postoperative photo documentation. NT increased oral commissure excursion from 0.4 mm (SD 5.3) to 2.9 mm (SD 6.8) (P = 0.05), and improved symmetry of excursion (P < 0.001) and angle (P < 0.001). FGMT increased oral commissure excursion from -1.4 mm (SD 3.9) to 2.1 mm (SD 3.7), (P = 0.02), and improved symmetry of excursion (P < 0.001). FaCE scores improved in NT patients postoperatively (P < 0.001).

CONCLUSIONS

Measuring outcomes, critical analyses, and a multidisciplinary approach are necessary components when building a facial nerve center. At our emerging facial nerve center, we found NT and FGMT procedures improved smile excursion and symmetry, and improved QOL following NT in patients with facial palsy secondary to multiple etiologies.

Advances in facial nerve management in the head and neck cancer patient

PURPOSE OF REVIEW

The purpose of this review is to summarize best practices in facial nerve management for patients with head and neck cancer. In addition, we provide a review of recent literature on novel innovations and techniques in facial reanimation surgery.

RECENT FINDINGS

Although recommended when tumor ablation surgery requires facial nerve sacrifice, facial reanimation procedures are not always performed. Concurrent dynamic facial reanimation with masseteric nerve transfers and cable graft repair can preserve native facial muscle function. Static suspension can provide facial support and immediate resting symmetry for patients. Eyelid weight and eye care should not be delayed, particularly in patients with trigeminal sensory deficits. Choice of neural source to innervate a gracilis-free muscle transfer for smile reanimation remains controversial; however, new techniques, such as dual innervation and multivector muscle transfer, may improve aesthetic and functional outcomes.

SUMMARY

Management of the facial nerve in the setting of head and neck cancer presents unique challenges. When possible, simultaneous oncologic resection and facial reanimation is ideal given the open surgical field, newly dissected and electrically stimulatable facial nerve branches, as well as minimizing postoperative healing time to prevent postsurgical treatment delays. A coordinated approach to facial nerve management with a multidisciplinary surgical team may help provide optimal, comprehensive care.

Dermal Filler Treatment Improves Psychosocial Well-Being in Facial Paralysis Patients

Background: In the care of the facial paralysis (FP) patient, outcomes have historically focused on facial function rather than the psychosocial burden of the disease state. Yet, FP patients often describe the impact of their disease on domains of psychosocial health. These patient concerns have motivated clinicians to formally recognize and treat nonfunctional sequelae of the disease. Dermal filler therapy (DFT) is a minimally invasive reversible procedure that can be used to treat facial asymmetry and improve psychosocial well-being in FP patients. However, there are no data describing outcomes of DFT in FP-related facial asymmetry. Therefore, we sought to formally characterize FP patients' facial symmetry and psychosocial well-being before and after DFT. Methods: FP patients presenting for DFT at a tertiary academic medical center were prospectively interviewed. Patients completed the validated FACE-Q for Appearance-Related Psychosocial Distress instrument. Self-reported facial symmetry scores were recorded. Patients were evaluated before and 2 weeks after DFT. Statistical analysis was performed on R software using paired sample t-tests. Results: Twenty FP patients completed DFT treatment and two surveys. The cohort was predominantly female (n = 19, 95%) with an average age of 54 years. After a single treatment of DFT averaging 2.3 mL, patients had significant improvement in facial symmetry and psychosocial well-being. Patients felt particular improvement in self-confidence and emotional expression (p < 0.0001 for all stated comparisons). Conclusion: FP of varying etiologies is associated with significant functional, psychosocial, and quality-of-life impairments. This is the first prospective study to demonstrate statistically significant improvements in facial symmetry and psychosocial well-being after a single office-based treatment of dermal filler. In addition, our study's emphasis on psychosocial health instruments reflects an increased awareness of this important domain in the care of the FP patient.

Masseteric-to-Facial Nerve Transfer and Selective Neurectomy for Rehabilitation of the Synkinetic Smile

Importance

Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. Current treatments for synkinesis include biofeedback for muscular retraining and chemodenervation via the injection of botulinum toxin. Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long-term maintenance injections and may lose effectiveness over time. A permanent solution for synkinesis remains elusive.

Objective

To evaluate masseteric-to-facial nerve transfer with selective neurectomy in rehabilitation of the synkinetic smile.

Design, Setting, and Participants

In this case series, 7 patients at a tertiary care teaching hospital underwent masseteric-to-facial nerve transfer with selective neurectomy for synkinesis between September 14, 2015, and April 19, 2018. The medical records of these patients were retrospectively reviewed and demographic characteristics, facial palsy causes, other interventions used, and changes in eFACE scores were identified.

Intervention

Masseteric-to-facial nerve transfer.

Main Outcomes and Measures

Changes in eFACE scores (calculated via numeric scoring of many sections of the face, including flaccidity, normal tone, and hypertonicity; higher scores indicate better function and lower scores indicate poorer function) and House-Brackmann Facial Nerve Grading System scores (range, 1-6; a score of 1 indicates normal facial function on the affected side, and a score of 6 indicates absence of any facial function [complete flaccid palsy] on the affected side).

Results

Among the 7 patients in the study (6 women and 1 man; median age, 49 years [range, 41-63 years]), there were no postoperative complications; patients were followed up for a mean of 12.8 months after surgery (range, 11.0-24.5 months). Patients experienced a significant improvement in mean (SD) eFACE scores in multiple domains, including smile (preoperative, 65.00 [8.64]; postoperative, 76.43 [7.79]; P = .01), dynamic function (preoperative, 62.57 [15.37]; and postoperative, 75.71 [8.48]; P = .03), synkinesis (preoperative, 52.70 [4.96]; and postoperative, 82.00 [6.93]; P < .001), midface and smile function (preoperative, 60.71 [13.52]; and postoperative, 78.86 [14.70]; P = .02), and lower face and neck function (preoperative, 51.14 [16.39]; and postoperative, 66.43 [20.82]; P = .046). Preoperative House-Brackmann Facial Nerve Grading System scores ranged from 3 to 4, and postoperative scores ranged from 2 to 3; this change was not significant.

Conclusion and Relevance

This study describes the application of masseteric-to-facial nerve transfer with selective neurectomy for smile rehabilitation in patients with synkinesis, with statistically significant improvement in smile symmetry and lower facial synkinesis as measured with the eFACE tool. This technique may allow for long-term improvement of synkinesis and smile. This study is only preliminary, and a larger cohort will permit more accurate assessment of this therapeutic modality.

Level of Evidence

4.

Facial mobility and recovery in patients with unilateral facial paralysis

OBJECTIVE

(a) To quantify longitudinal 3D changes in facial soft tissue movements in adults with unilateral facial paralysis, and (b) to compare the patients' movements with an age- and sex-frequency matched control group.

SETTINGS AND SAMPLE POPULATION

Prospective 3D facial movement data of 36 patients and 68 control participants. Patients' data were collected within 6 weeks of onset of symptoms (baseline) and then at 3 and 12 weeks after baseline.

MATERIALS AND METHODS

The 3D facial movement data were collected during different facial animations. Mean group measurements of displacement, velocity and asymmetry were computed. Two sample t tests were used to test for significant group differences, and linear mixed models were fit to test for significant changes over time in the patient group. Also, 3D dynamic modelling and vector plots were computed to isolate the patients' abnormal movements and/or paralysis.

RESULTS

The patients' mean baseline movements were significantly less for both the paralysed and contralateral sides of the face with much greater movement asymmetry than the controls. Patients' mean measures improved significantly from baseline to 12 weeks. The measures were closer to, but fell short of, the control values.

CONCLUSION

In unilateral facial paralysis, the contralateral facial side was affected by the paralysis and may be tethered or limited in its movement by the paralysed side. The comprehensive measurement set and 3D facial mapping effectively tracked patient recovery and isolated paralysed facial regions. The 3D measures can be used for diagnosis and outcome assessment of different treatments.

[Facial paralysis sequelae: Long term follow-up revision surgery, redo, continuing care]

Facial paralysis sequelae have an intense psycho-social impact which imposes an optimal care in the long run. The surgical challenges are numerous, and the therapeutic weapons are multiple. We propose an analysis of these treatments by the prism of their pitfalls and their limits. The complications of the main surgical procedures are described as well as the details of the rework necessary to cope with them or to quickly correct the defects. Moreover, the result limits are detailed with suggestions to improve them. Finally, we develop the necessary iterative treatments or new therapeutic proposals that are essential for the long-term care of these patients whose sequelae of facial paralysis evolve with time and aging. The surgery of facial paralysis is not unequivocal. It requires humility, patience and tenacity to support the patient throughout his life.